Page 25 - 2020 Benefits Guide
P. 25
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MAX BENEFIT
WHAT IS COVERED
PER PERSON
In Patient Benefits • Hospital confinement due to a covered
Pays benefits up to illness or injury
the amount shown, per • Hospital emergency room treatment $4000
covered person, per
calendar year
Outpatient Benefits • Outpatient treatment due to a covered
Subject to a per family/per injury or sickness at a hospital $2000
calendar year maximum • Outpatient surgical or emergency not to exceed
of two individuals facility or a diagnostic testing facility or $4,000 per family
similar facility that is licensed to provide per year or two
outpatient treatment individuals covered
• This includes radiation and in the year
chemotherapy.
Not Covered • Copays for office visits and prescription
drugs
• Expenses not covered by the BCBS
Medical Plan
• Expenses related to mental/nervous
disorders or treatment for substance $0
abuse (even though such expenses ARE
covered by the BCBS Medical Plans)
• Otherwise eligible expenses which are
paid by the Medical Plan at 100%; only
expenses applied to deductible and
coinsurance are reimbursable.
Jina Pyun, Senior Benefits Analyst
Dallas, TX
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